Bullying Prevention and Intervention Reporting Form
Name of Reporter/Person Filing the Report
Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.
Check whether you are the:
Target of the behavior
Reporter (not the target)
Check whether you are a:
What school do you attend or work at?
What grade are you in?
What school do you work at?
What is your role at the school?
How can we contact you for follow up discussions?
Name of Target (of behavior):
Name of Aggressors (Persons who engaged in the behavior):
Date(s) of Incidents(s):
Time When Incident(s) Occurred:
Witnesses (List people who saw the incident or have information about it):
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
By checking this box, I affirm that the information I am entering is the accurate to the best of my knowledge.
Should be Empty: